Transcript Document 7270913

Could Arthritis Be a Barrier to Physical
Activity Among Persons with Diabetes
and Other Chronic Conditions?
J. Bolen, C. Helmick, J. Hootman,
T. Brady, L. Ramsey.
CDC Arthritis Program
Format for today’s call
• Prevalence of arthritis among people with diabetes,
heart disease, obesity, inactivity.
• Characteristics of people with arthritis who are and
are not physically active
• Arthritis as a barrier to increased physical activity
– Characteristic of successful exercisers with arthritis
– Arthritis-specific interventions
• Examples of successful collaborations between
state arthritis programs and other chronic disease
programs
2
Take home message
Anyone seeking to increase physical activity in
the population of adults with other chronic
diseases or risk factors (e.g. diabetes
cardiovascular disease, obesity and physical
activity) has to address arthritis.
- A large proportion of people with chronic
diseases also have arthritis.
- Arthritis presents unique barriers to
increased physical activity.
3
Prevalence of arthritis among adults with diabetes,
heart disease, obesity and physical inactivity
Julie Bolen, PhD, MPH
[email protected]
4
Almost Half of Adults with Diabetes
also Have Arthritis (NHIS, 2003-2005)
(46.4 million)
Arthritis
Diabetes (17.2 million)
7.8 million
people
with both
5
Over Half of Adults with Heart Disease
also Have Arthritis (NHIS, 2003-2005)
(46.4 million)
Arthritis
Heart Disease
(13.3 million)
6.9 million
people
with both
6
Arthritis among adults with diabetes,
heart disease, obesity, inactivity:
2003-05 BRFSS State Medians.
70
60
50
40
18+
Men
Women
30
20
10
0
Arth
Diabetes Heart Dis Obesity
Inactive
7
Increased physical activity
(conditioning and strengthening) helps
several chronic conditions
– For people with arthritis, can reduce joint pain,
improve function, and improve mental health
– For people with diabetes, can reduce blood
glucose and risk factors for complications
– For people with heart disease, can improve
cardio-vascular functioning and help control
weight
8
Addressing arthritis is critical
• There are barriers to increasing physical
activity faced by most adults, e.g. lack of
time, motivation, competing
responsibilities, etc
• Also arthritis-specific barriers, e. g. pain,
fear of increased pain and possible joint
damage, don’t know which activities are
“safe”
9
State-specific data for diabetes
• Below are examples from the 2003-2005
BRFSS demonstrating the high prevalence
of arthritis among adults with diabetes
• State medians and ranges are presented
10
Definitions
Case Definitions Diabetes, Arthritis, and Obesity
• Have you ever been told by a doctor that you have
diabetes?
• Have you ever been told by a doctor or other health
professional that you have some form of arthritis,
rheumatoid arthritis, gout, lupus, or fibromyalgia?
• Body Mass Index > 30 is obese
- About how tall are you without shoes?
- About how much do you weigh without shoes?
11
Definitions
Physical Activity
• Physical activity is estimated from a combination of 6
questions that puts people into one of 3 categories.
• We focus on those who are Inactive (no reported
moderate or vigorous activity)
• Moving people from the inactive group to a higher level
of activity provides most benefit
12
Prevalence of Arthritis Among Adults with
Diabetes Median 52.6% (Range 36.2% HI – 59.3% MO)
36.2 – 48.8
49.3 – 55.0
55.2 – 59.3
13
Arthritis Among People with
Diabetes by Age, Sex, and Race
(state medians)
70
66
60
Percent
56
53
50
55
53
44
40
35
30
28
20
10
0
18-44
45-64
Age
65+
M
F
Sex
White
Black
Hispanic
Race
14
Arthritis Prevalence Among Adults in the
General Population and Adults with
Diabetes by Age Group
Age
Group
Median all Median and Range
adults
People with diabetes
18-44
11%
28% (13% CO – 42% VA)
45-64
36%
53% (33% HI – 61% MS)
65+
56%
63% (45% HI – 71% MS)
15
Prevalence of Arthritis among Adults with
Diabetes who are Inactive
Median 61.1% (Range 43.9% CA – 73% IA)
43.9 – 56.9
57.0 – 63.9
64.0 – 73.0
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Prevalence Data Summary
Diabetes and Arthritis
•
Overall, arthritis affects over half of the adults
with diabetes. (Also true for heart disease)
•
Arthritis is especially prevalent among women
and adults 45 years and older with diabetes.
(Also true for heart disease)
•
Arthritis prevalence among people with
diabetes who are inactive is about 61%, with
state estimates ranging from 44% to 73%.
17
Characteristics of people with arthritis who are
and are not physically active
Jennifer Hootman, PhD, MPH
[email protected]
18
Healthy People 2010 PA Objectives
22-1 Reduce % inactive (no LTPA)
22-2 Increase % engaging in moderate PA (5x30)
22-3 Increase % engaging in vigorous PA (3x20)
22-4 Increase % performing strengthening
exercises
People with arthritis are a specific target group for these objectives.
19
Arthritis-specific PA
recommendation
• Expert Panel – 2002 St. Louis Conference
International Conference on Health Promotion and
Disability Prevention for Individuals and Populations
with Rheumatic Disease: Evidence for Exercise and
Physical Activity
• Evidence for at least 3x30 moderate PA
recommendation for adults with arthritis
•
•
•
•
“Lowers the bar” for frequency per week
Emphasizes moderate intensity
“Joint Friendly” - low impact
Can do in 10-15 min increments
Reference: Arthritis and Rheumatism 2003;49(3): 453-454.
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Risk of "Poor Outcome"
Theoretical Rationale
2.5
Very High Activity
2
Immobile/inactive
1.5
High Activity
1
0.5
0
Low to moderate
activity
Optimal Range
21
CDC Arthritis Program Focus
• CDC emphasizes just getting out of the
inactive category
• Gives “biggest bang for the buck”
• Easier to identify target group (e.g. “inactives”)
• Refer to arthritis-specific community-based exercise programs
22
Meeting PA Recommendations*
US Adults With and Without Arthritis
50
Percent (%)
40
2002 National Health Interview Survey
43.6
39.5
36.4
30
33.4
32.3
Arthritis
No Arthritis
25.8
21.5
16.3
20
10
0
Inactive
Meet Gen Rec
Meet Arth Rec
Streng Ex
* HP2010 Goal
Source: Shih M, et al. Am J Prev Med, 2006;30(5):385-93.
23
Factors associated with inactivity
among adults with arthritis
More inactive:
•
•
•
•
•
•
•
•
•
•
Females
Older age (45+ yrs)
Race/Ethnicity (NHB, Hisp)
Education (HS or less)
Frequent Anxiety/Depression
Functional limitations
Social limitations
Special equipment
Severe joint pain
No HCP counseling for ex
Source: Shih M, et al. Am J Prev Med, 2006;30(5):385-93.
Less inactive:
• Perceived access to fitness
program/facility
No association:
• Body mass index
• Presence and number of comorbid conditions
• Location of joint pain
24
Arthritis as a barrier to increased physical
activity
Characteristic of successful exercisers
with arthritis
Arthritis-specific interventions
Examples of successful collaborations
between state arthritis programs and other
chronic disease programs
Teresa Brady, PhD
[email protected]
25
Common Barriers
Groups
•
•
•
•
•
•
•
Fatigue
Lack time
No ex. buddy
Should/don’t
Not a priority
Other priorities
Don’t enjoy
Exer.
100%
83%
50%
50%
67%
33%
50%
Non-Ex
100%
50%
83%
67%
33%
67%
50%
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Barriers to Physical Activity
Among People with Arthritis
• Purpose
– Identify barriers to PA among PWA
– Compare regular exercises/non-exercisers
• 12 focus groups, segmented by
– Exercise status (30 min--3 days/no more than
20 min--2 days
– Race (Caucasian/African American)
– SES (HS Ed or less/more than HS)
27
Arthritis Specific Barriers
Groups
Exer Non-exer
• Pain
100% 100%
83% 100%
• Perceived neg.
outcomes
83% 100%
• No Arthritis specific
pgm
• Weather
83% 67%
• Dr. not mention
50% 50%
28
Additional Arthritis Specific
Barriers among Non Exercisers
Groups
•
•
•
•
“I can’t”
Lack pos. outcomes
Fear
Dr. not refer
Exer. Non-Ex
17%
0%
0%
0%
67%
67%
50%
50%
29
Conclusions
• PWA face both general and
arthritis specific barriers to PA
• Among PWA Exercisers and Nonexercisers face many of the same
barriers
• Exercisers less likely to allow
barriers to prevent exercise
– Exercisers modified their exercise
– Non-Exercisers gave up exercise
30
Implications
To increase physical activity among
PWA :
• Address fear and other
psychological barriers
• Provide arthritis specific
instruction and referral to programs
• Increase arthritis specific
facilities/programs
• Incorporate problem-solving skills
31
Addressing Barriers to Physical
Activity among People with Arthritis
Use evidence-based interventions to:
• Instruct on appropriate physical
activity
• Address fears
• Provide arthritis-safe exercise
• Teach problem solving skills
32
Evidence-Based Interventions
• Self Management Education
Programs
• Physical Activity/Exercise
Programs
• Health Communications
33
Evidence-Based
Interventions:
• Self Management Education
Programs
– Chronic Disease Self Management
Program
– Arthritis Self Management Program
(Arthritis Foundation Self-Help
Program; aka ASHC)
34
Self Management Education
Chronic Disease Self Management
Program (CDSMP):
•
•
•
•
Small group classes
Lead by trained lay leaders
6 weeks; 2 ½ hours week
Designed to teach generalizable skills and
enhance self efficacy
– Goal setting, action planning
– Problem-solving, communication with providers
• Addresses multiple chronic conditions
• Developed, evaluated by Stanford University
35
Self Management Education
Chronic Disease Self Management Program
(CDSMP)
Improved Outcomes:
Self efficacy
6 mo.
√
2 yrs.
√
Self rated health
Disability
Role activity
Energy/fatigue
Health distress
√
√
√
√
√
√
MD/ER visits
Hospitalization
√
√
√
Lorig et al 1999, 2001
√
√
36
Arthritis Self Management Program/
Arthritis Foundation Self Help Program
• Small group education
• Covers problem-solving, exercise, relaxation,
communication, etc.
• 6 week series of 2-2.5 hours/week
• Taught by trained volunteers
• Designed to increase self efficacy
• Developed by Stanford University
• Disseminated by AF since 1981
37
Evidence-Based Interventions
• Self Management Education
Programs
– CDSMP/ASMP
• Physical Activity/Exercise Programs
• Health Communications
38
Evidence-Based Interventions:
• Physical Activity/Exercise Programs
– EnhanceFitness
– Arthritis Foundation Exercise program
(aka PACE)
– Arthritis Foundation Aquatics Program
39
Physical Activity Interventions
EnhanceFitness:
• Multi-component group exercise
program
– Flexibility, Strengthening, Conditioning,
Balance components mandatory
• Led by certified fitness instructors
• Generic; not arthritis specific
• Safe for physically unfit seniors
including ‘near frail’
• Developed and evaluated at Univ. of
WA
• Disseminated by Project Enhance
40
Physical Activity Interventions
EnhanceFitness—Initial Study Results (RCT)
• 85% completion rate
• Significant improvements in:
–
–
–
–
–
–
Depression
General health perception
Mental health
Lack of role limitations
Social function
Energy/fatigue
• Trend toward significance in
– Pain
– Physical function
» Wallace et al J Gerontology 1998
41
Arthritis Foundation
Exercise Program
• Community recreational exercise program
• Endurance and relaxation activities, health
education
• Basic and advanced levels
• 1-1.5 hrs, 1-3 times per week, 8 wks
• Activities seated, standing or lying
• Health/fitness professionals instructors
• Developed by AF in 1987, revised in
1999
42
Arthritis Foundation Aquatic Program
• Moderate intensity aquatics group program;
video available
• Covers ROM, strength and endurance
• Basic and advanced levels
• 1-hr session,1-3 times per wk, 6-10 wks
• Taught by trained fitness/health leaders
• Co-developed with YMCA in 1983,
revised as needed every 3 years
43
AF Physical Activity/
Exercise Programs:
Aquatics PACE
Knowledge
Exercise Fx
Relaxation Fx
Self Care Behav.
Self Efficacy
Pain
Depression
Helplessness
Disability/Function






Jt. Efforts
Educize






Brady, Kreuger, et al 2003
44
Evidence-Based Interventions:
• Self Management Education Programs
• Physical Activity/Exercise Programs
– EnhanceFitness
– Arthritis Foundation Exercise program
(aka PACE)
– Arthritis Foundation Aquatics Program
• Health Communications
– Physical Activity. The Arthritis Pain
Reliever
– Buenos Diaz, Artritis
45
Health Communications
The use of communication strategies
to inform and influence individual and
community decisions that enhance health.
To be effective: Messages and materials
need to resonate with the target audience
46
English Health Communications
Campaign
• Directed toward Caucasian and African
American adults with arthritis
– Ages 45-70, lower SES
• Released in 2003
• Used by 35 state health departments, at
least 10 Arthritis Foundation Chapters
• Address key motivators
– Pain relief; ability to do more
47
Key Public Health Message
• 30 minutes of moderate activity
• At least 3 days per week*
– ACR consensus recommendations
– Arth Rheum 2003;49: 453-454
• Can be done in 10 minute
increments (makes it do-able)
48
Campaign Materials:
• Radio Spot
• Recorded
• Script for local live announcer
• Brochure and Brochure Holder for
pharmacies, MD offices churches, etc
• Print PSAs
• Posters
49
Themeline:
Physical Activity.
The Arthritis Pain Reliever.
50
Campaign Materials
51
Physical Activity. The Arthritis Pain Reliever.
Pilot Test Results
N = 1200, from 4 sites
• 50% have read/heard something
about relieving arthritis pain with PA
in past mo.
• 20% increased PA in last month in
response to something heard/read
• 92% agree that moderate PA can be
helpful even if done 10 min./time
52
Physical Activity. The Arthritis Pain Reliever.
Controlled Trial Results
6 month follow up, N = 300 (E1, E2, C)
• Campaign recognition significantly greater
in E1
• Significant baseline-follow up changes in
E1
– Knowledge
• Moderate PA can reduce arthritis pain
• Moderate PA helpful 10 min./time
• Possible to relieve arthritis pain without meds
– Behavior: participation in moderate PA
53
Hispanic Campaign
• Designed to promote physical activity
among Spanish-speaking people with
arthritis
• Target audience similar to English
campaign
• Objectives similar to English campaign
• Materials similar to English campaign
– + outdoor advertising
• Concepts and executions different
54
55
Buenos Dias, Artritis
Pilot Test Summary Results
Telephone survey: N = 817 (CA, FL, OK, WI)
• 2/3rd Read/heard something about exercise to
beat arthritis
• 27% Increased exercise in response to something
heard/read in past month
• 29% likely to increase exercise in next month
• 88% agree exercise helpful even 10 minutes/time
• 3 states modest increase to AF Spanish info line
after campaign
56
Evidence-Based
Interventions:
• Self Management Education Programs
– Chronic Disease Self Management Program
– Arthritis Self Management Program (Arthritis
Foundation Self-Help Program; aka ASHC)
• Physical Activity/Exercise Programs
– EnhanceFitness
– Arthritis Foundation Exercise program (PACE)
– Arthritis Foundation Aquatics Program
• Health Communications
– Physical Activity. The Arthritis Pain Reliever
– Buenos Diaz, Artritis
57
Missouri Arthritis Program Collaboration with
Missouri Diabetes Program
— Regional Arthritis Center
58
Other examples of state program collaboration
• Kentucky Arthritis Program and Physical Activity and Nutrition Program are
working together to expand the reach of multiple evidence based interventions
through their local health department structure.
• Michigan “Partners on the Path”
-Arthritis Program is involved in a statewide initiative to expand the
reach of Chronic Disease Self Management Program (CDSMP)
through Area Agencies on Aging (AAAs) and the Diabetes Outreach
Network (DON).
59
Public Health Implications
• Diabetes and other chronic disease programs could
improve success in promoting physical activity by
addressing arthritis as a potential barrier
• Arthritis, diabetes, cardiovascular health, and obesity
programs are targeting many of the same people with a
similar message: increase physical activity
• Evidence-based programs can help people with arthritis
and other chronic conditions become more physically
active.
60
Future Plans
Evaluation of general physical activity communitybased program
– “Active Living Every Day”
– Additional evaluation of “Enhance Fitness”
• Evaluation of arthritis-specific walking program
– “Arthritis Foundation Walk with Ease”
• Develop new, more challenging land-based and
group exercise programs for people with arthritis
– Fitness and exercise for people with arthritis.
61
Questions?
62